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Obesity: Surgical and Pharmaceutical options & Navigating diet trends
Guillermo Higa MD, FACS, FASMBSBariatric Surgery Medical Director
Chief of Division of Bariatric SurgerySt. Mary’s Hospital
Tucson-Arizona
What is Obesity?
The Obesity Medicine Association Definition of Obesity
• “Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.”
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Obesity is common, serious, and costly• The prevalence of obesity was 39.8% and affected about
93.3 million of US adults in 2015-2016.
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer that are some of the leading causes of preventable, premature death.
• The estimated annual medical cost of obesity in the United States was $147 billion in 2008 US dollars; the medical cost for people who have obesity was $1,429 higher than those of normal weight.
https://www.cdc.gov/obesity/data/adult.html
Obesity Kills
• Leading cause of preventable death
• Recently surpassed smoking as leading cause
• Lifespan shortened 9 - 12 years
• Over 400,000 deaths per year
• 46 deaths each hour
Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2017
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Obesity Prevalence
• In 2015 – 2016, the prevalence of obesity is estimated to be ~ 40% in US adults, and 18.5% of youths
• The prevalence of obesity is higher among non-Hispanic black and Hispanic adults than among non-Hispanic white and non-Hispanic Asian adults and youth
• At least since 1999, the trend towards an increase in prevalence in obesity continues to increase among adults and youths
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [2]
Genetics/ Epigenetics
Environment(Social/Culture)
Immune
Endocrine
Medical
Neurobehavioral
Obesity as a Multifactorial Disease
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Obesity: Epigenetic Etiology/CausesEpigenetics: Alterations in gene expression without alteration in the genetic codePre-pregnancy
• Pre-conception paternal or maternal overweight/obesity may influence epigenetic signaling during subsequent pregnancy:‒ Increased risk of overweight/obesity in offspring‒ Increased risk of other diseases (e.g., cardiovascular disease, cancer, diabetes mellitus, etc.) in offspring
Pregnancy• Especially in the presence of gestational diabetes mellitus, unhealthy maternal nutrition in women who are
pregnant and overweight or with obesity may increase placental nutrient transfer to fetal circulation:‒ Glucose‒ Lipids and fatty acids‒ Amino acids
• Increased maternal nutrient transport may alter fetal gene expression:‒ Covalent modifications of deoxynucleic acid and chromatin‒ May impact stem cell fate‒ May alter postnatal biologic processes involved in substrate metabolism‒ May increase offspring predisposition to overweight/obesity and other diseases
Post-pregnancy• Adverse effects of epigenetic pathologies may help account for generational obesity• Improvement in generational obesity in offspring will likely require generational change in
nutrition and physical activity in prior generations of parents
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [7] [11] [12]
Obesity: Extragenetic Etiology/Causes
Extragenetic• Environment (family, home, geographic location)• Culture• Lack of optimal nutrition and physical activity• Disrupted sleep (e.g., poor quality, too little, or too much)• Adverse consequences of medications• Mental stress• Neurologic dysfunction (central nervous system trauma, hypothalamic inflammation,
leptin resistance) • Viral infections• Gut microbiota neurologic signaling and transmission of pro-inflammatory state
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [7]
Obesity is common, serious, and costly• The prevalence of obesity was 39.8% and affected about
93.3 million of US adults in 2015-2016.
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer that are some of the leading causes of preventable, premature death.
• The estimated annual medical cost of obesity in the United States was $147 billion in 2008 US dollars; the medical cost for people who have obesity was $1,429 higher than those of normal weight.
https://www.cdc.gov/obesity/data/adult.html
Nutritional Intervention Physical Activity Pharmaco-
therapyBariatric
ProceduresBehavior Therapy
Motivational Interviewing
Management Decisions
Evaluation and Assessment
Obesity Algorithm
Obesity as a Disease
Data Collection
Reference/s: [1]Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Which Is the “Best” Measure of Obesity?Population Assessment
• Body mass index (BMI), waist circumference (WC), and percent body fat (%BF) similarly correlate with prevalence of metabolic syndrome
Individual Assessment • BMI is a reasonable initial screening measurement for most patients
• WC provides additional information regarding adipose tissue function/dysfunction and predisposition to metabolic disease among individuals with BMI<35 kg/m2
• %BF may be more useful in patients with extremes in muscle mass (i.e., individuals with sarcopenia or substantial increases in muscle mass), and thus may be a more accurate measure of body composition when assessing the efficacy of interventions directed towards change in muscle mass
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [1]
Acceptable Weight 18 – 25Overweight 25 – 30Obese 30 – 35Severe Obesity 35 – 40Morbid Obesity 40 – 50Super Morbid Obesity above 50
BMI = weight (kg)/height (m²)= [weight (lbs)/height (in²)] x 703
Waist Circumference: Increased Body Fat (Adiposity)
Obesity classification:Waist circumference (WC)*
Abdominal Obesity - Men> 40 inches
> 102 centimeters
Abdominal Obesity - Women> 35 inches
> 88 centimeters
*Different WC abdominal obesity cut-off points are appropriate for different races (i.e., > 90 centimeters for Asian men and > 80 centimeters for Asian women)
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [23] [24] [25] [26]
Waist Circumference
Advantages • Well-correlated to metabolic disease • Direct anatomical measure of adipose tissue deposition, with an increase in waist
circumference reflective of adipose tissue dysfunction• Low cost
Disadvantages• Measurement not always reproducible• Waist circumference is not superior to BMI in correlating to metabolic disease in
patients with BMI > 35 kg/m2
• Racial/ethnic differences
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [24] [25] [26]
Overall Management Goals
Adult patient with overweight or obesity
Improve patient health
Improve quality of life
Improve body weight and composition
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Nutritional Intervention Physical Activity Pharmaco-
therapyBariatric
ProceduresBehavior Therapy
Motivational Interviewing
Management Decisions
Evaluation and Assessment
Obesity Algorithm
Obesity as a Disease
Data Collection
Reference/s: [1]Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
• Ask for permission to discuss body weight.• Explore readiness for change.Ask
• Assess BMI, waist circumference, and obesity stage.• Explore drivers and complications of excess weight.Assess
• Advise the patient about the health risks of obesity, the benefits of modest weight loss (i.e., 5-10 percent), the need for long-term strategy, and treatment options.
Advise
• Agree on realistic weight-loss expectations, targets, behavioral changes, and specific details of the treatment plan.Agree
• Assist in identifying and addressing barriers; provide resources; assist in finding and consulting with appropriate providers; arrange regular follow up.
Arrange/Assist
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Motivational Interviewing Techniques: 5A’s of Obesity Management
Reference/s: [226] [227]
Pre-contemplationUnawareness of the problem
ContemplationThinking of change in the next 6 months
PreparationMaking plans to change now
ActionImplementation of change
RelapseRestart of unfavorable behavior
Motivational Interviewing: Stages of Change
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Progress
Reference/s: [204] [205]
Nutrition Physical Activity Behavior Therapy Pharmacotherapy Bariatric Surgery
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Medical Management and Coordination
Treatment of Adult Patients with Overweight or Obesity
Reference/s: [1]
Nutritional Therapy for Obesity
Nutrition HistoryMeals and Snacks
• Timing• Frequency (via questionnaire)• Nutritional content• Preparer of food• Access to foods• Location of home food
consumption (i.e., eating area, television, computer, etc.)
• Location of away food consumption (i.e., workplace restaurants, fast food, etc.)
Behavior
• Previous nutritional attempts to lose weight and/or change body composition‒ If unsuccessful or un-
sustained, what were short- and long-term barriers to achieving or maintaining fat weight loss
• Triggers (hunger, cravings, anxiety, boredom, reward, etc.)
• Nighttime eating• Binge eating• Emotional eating• Family/cultural influences • Community influences • Readiness for change
Records
• Food and beverage diary, including type of food or beverage consumed and amount consumed ‒ 72-hour recall‒ Keep food and beverage
record for a week and return for evaluation
• Electronic application tools
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [78] [79] [80]
Carbohydrates• Carbohydrates contain 4 kcal/gram• Carbohydrates can serve as a source of energy and as well cellular structural
elements such as hyaluronic acid and proteoglycans• Carbohydrates may contain sugars, starch and/or fiber• The digestion and absorption of carbohydrates results in monosaccharide (glucose,
fructose, galactose) molecules• Carbohydrates are not an essential macronutrient, as the liver and kidney can
synthesize glucose• Calorie deficiency can lead to marasmus (insufficient calories), but there is no
known carbohydrate deficiency• USDA DRI for carbohydrate is 130 grams/day
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [146]
• Fat contains 9 kcal/gram• Fats or lipids are a diverse group of compounds used as an energy source and for many metabolic
processes: • Immune response (omega-3 fatty acids)• Cell membrane structure (phospholipids)• Brain tissue (cerebrosides)• Synthesis of bile acid, cholesterol, vitamin D, steroid hormones• Insulation
• Several fatty acids cannot be made by the body and these “essential” fatty acids must be consumed in the diet
• Fatty acid deficiency can lead to a disease state• USDA DRI for fat is at least 30 grams/day• Replacing saturated fats with polyunsaturated or monounsaturated fats may reduce cardiovascular disease
risk• Replacing saturated fats with refined carbohydrates and sugar is not associated with reduced cardiovascular
disease risk
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Fat
Reference/s: [146] [147]
Why Do We Need Protein?• Growth & maintenance of tissues• Biochemical reactions depend on enzymatic function
• Digestion, energy production, blood clotting, muscle contraction
• Endocrine functions• Protein & polypeptides make up most of body’s hormones
• Provides structure• Fibrous protein makes up keratin, collagen, and elastin
• Maintains proper pH & fluid balance• Immune health• Transport & store nutrients• Energy source in fasting states
Protein
• Protein contains 4 kcal/gram• Protein contains amino acids and serves as the major structural building
blocks of the human body: bone, muscle, skin, brain, nucleic acids• Essential amino acids are those which cannot be made by the human body
and must be consumed in the diet• Some amino acids can be used as an energy source (converted to glucose
or ketones when needed)• Protein deficiency can lead to a disease state (Kwashiorkor is sufficient
calories but insufficient protein)• USDA DRI (Dietary Reference Intake) for protein is 0.8 to 2.0 grams/kg/day
depending upon age, gender, physical activity
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [146]
Principles of Healthy NutritionLimit:• Highly processed foods of minimum nutritional value: sweets, “junk foods,” cakes, cookies,
candy, pies, chips• Energy-dense beverages: sugar-sweetened beverages, juice, cream
Encourage: • Consumption of healthy proteins and fats, vegetables, leafy greens, fruits, berries, nuts,
legumes, whole grains• Complex carbohydrates over simple sugars: Low glycemic index over high glycemic index foods• High-fiber foods over low-fiber foods• Reading labels rather than marketing claims
Managing the quality of calories is important when reducing the quantity of calories, such as during weight loss.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [1] [148]
Nutritional Therapy for Obesity
Evidence-based Quantitative QualitativePatient preference
Patient adherence
Factors related to improved outcomes:
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [1]
Choosing Nutritional Therapy for Obesity
• Encourage foods that result in a negative caloric balance to achieve and maintain a healthy weight
• Consider the following:• Individual food preferences, eating behaviors, and meal patterns• Cultural background, traditions, and food availability• Time constraints and financial issues• Nutritional knowledge and cooking skills
The most appropriate nutritional therapy for weight loss should be safe, effective, and one to which the patient can adhere.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [1]
Choosing Nutritional Therapy for Obesity
• Nutritional approaches for weight loss typically focus on the caloric manipulation of the three macronutrients: carbohydrate, fat, or protein
• Very low-calorie diets contain less than 800 kcal/day and require close medical supervision for safety reasons
• Low calorie diets range from 1200-1800 kcal/day (1200-1500 for women, 1500-1800 for men)
• Restricting dietary fat leads to a greater reduction in total and LDL cholesterol, whereas restricting dietary carbohydrate leads to a greater reduction in serum triglycerides and an increase in HDL-cholesterol
• Reduction of carbohydrates can lead to a greater reduction in serum glucose and hemoglobin A1C
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [1]
Nutritional Therapy for ObesityEnergy consumption intended to cause negative calorie balance and loss of fat mass
Low-calorie diets:1,200-1,800 kcal/day
Restricted fat diet
Low-fat diet: <30% fat calories
Very low-fat diet: <10% fat calories
Restricted carbohydrate diet
Low-glycemic diet:
Low-carbohydrate diet50-150 grams/day
Very low carbohydrate diet<50 grams/day
(with or without nutritional ketosis)
Very low-calorie diets: Less than 800 kcal/day
Physician supervision recommended
Recommended for shorter durations
Commercial shakes, bars, and soups
which replace meals.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [149] [150] [151] [152]
Low-calorie Diets: Restricted-carbohydrate Diet
Weight Loss• May produce modestly greater weight loss compared to fat-restricted dietary intake for the first 6 months, wherein afterwards, the
net weight loss may be similar to other calorie restricted nutritional interventions• May assist with reducing food cravings
Metabolic Effects• Reduces fasting glucose, insulin and triglycerides • Modestly increases high-density lipoprotein cholesterol levels• May increase low-density lipoprotein cholesterol levels• May modestly reduce blood pressure• The metabolic effects noted above may occur with or without weight loss• In patients with epilepsy, a very low carbohydrate ketogenic diet (VLCKD) may reduce seizures• LCKD may possibly improve diabetes mellitus complications (i.e., nephropathy)
Risks• May produce carbohydrate cravings within the first few days of implementation, which may be mitigated by adding low-glycemic-
index carbohydrate foods• May induce gout flare if history of gout• May present challenges in patients undergoing dietary protein restriction (severe kidney disease)
Low-carbohydrate diet defined as 50-150 grams of carbohydrates per day.Very low-carbohydrate diet defined as <50 grams of carbohydrates per day.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [153] [154] [155] [156] [157] [158]
Low-calorie Diets: Restricted-fat Diet
Weight Loss• After six months, fat-restrictive, low-calorie nutritional intervention generally produces the same amount of weight loss
compared to the “low-carb diet”
Metabolic Effects• May reduce fasting glucose and insulin levels• Modestly decreases low-density and high-density lipoprotein cholesterol levels• May modestly reduce blood pressure
Risks• Hunger control may present challenges, which may be mitigated with weight-management pharmacotherapy • If fat restriction results in a substantial increase in carbohydrate consumption, and if weight loss is not achieved, an
increase in carbohydrate dietary intake may potentially contribute to hyperglycemia, hyperinsulinemia, hypertriglyceridemia, and reduced levels of high-density lipoprotein cholesterol
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Defined as 10-30% of total calories from fat.
Reference/s: [159] [160]
Very Low-calorie Diets
Weight Loss• Produces more rapid weight loss than low calorie (low-fat or carbohydrate restricted) diets due to the lower energy intake
Metabolic Effects • Reduces fasting glucose, insulin and triglycerides • May modestly increase high-density lipoprotein cholesterol levels• May modestly decrease low-density lipoprotein cholesterol• Reduces blood pressure
Risks• Fatigue, nausea, constipation, diarrhea, hair loss, and brittle nails• Cold intolerance, dysmenorrhea• Small increase in gallstones, kidney stones, gout flare• If insufficient mineral intake, then may predispose to palpitations and cardiac dysrhythmias, muscle cramps• Weight regain will occur if patients are not taught how to maintain healthy eating when transitioning
to non-meal replacement
Defined as less than 800 kcal/day, typically implemented utilizing specifically formulated meal-replacement products supervised by a trained clinician.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [161] [162]
Dietary Patterns
• Mediterranean diet• Therapeutic lifestyle diet• DASH (Dietary Approaches to Stop Hypertension)• Atkins diet• Ornish diet• Paleo diet• Vegetarian diet• Commercial diet programs
Includes many dietary patterns but must be calorically restricted to effectively treat obesity. Weight loss and metabolic effects vary.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
• Partially hydrogenated vegetable oils were developed because they favorably affected taste in applicable foods and were less expensive than saturated fats from animals (lard)
• Some early shortenings (fats) were made from partially hydrogenated vegetable oil (cottonseed and soybean oil), originally contained 50% trans fats, and were marketed as being a healthier alternative to animal fat, because they were derived from “vegetables”
• Although it contains partially hydrogenated palm and soybean oils, common shortenings now contain minimal trans fats, soybeanoil, fully hydrogenated palm oil (i.e., 3 grams saturated fats, 6 grams polyunsaturated fats, 2.5 monounsaturated fats)
• Trans fats may increase low-density lipoprotein cholesterol, reduce high-density lipoprotein cholesterol, and increase the risk of cardiovascular disease (myocardial infarction and stroke), type 2 diabetes mellitus, and certain cancers
• While the FDA has banned partially hydrogenated oil by 2018, trans fats can still be found in some cakes, pies, cookies (especially with frosting), biscuits, microwavable breakfasts, stick margarine, crackers, microwave popcorn, cream-filled candies, doughnuts, fried fast foods, and frozen pizza
• Conjugated linoleic acid (CLA) is a naturally occurring trans fat derived from ruminants (fermentation of plant-based foods via microbes in the stomach prior to digestion) which is not proven to be detrimental to health; conjugated trans linkages are not included as trans fats for nutritional regulations and food labeling
Trans fats are created through a process of artificially hydrogenating polyunsaturated fats (vegetable oils) into more saturated fats, allowing for higher melting temperatures more desirable for processed
foods, cooking and frying.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Trans Fats
Reference/s: [163] [164] [165]
The Mediterranean Diet is not a defined “diet,” but rather a generalized term to described several meal pattern variants often found in Greece, Italy, and Spain. The Mediterranean Diet has the most
consistent and robust scientific support in reducing atherosclerotic cardiovascular disease risk.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Olive oil as main source of fat• Vegetables, fruit, legumes, whole grains,
nuts, and seeds• Moderate intake of red wine• Moderate consumption of seafood,
fermented dairy products (cheese and yogurt), poultry, and eggs
Discouraged
• Limit consumption of high amounts of red meat, meat products, and sweets*
*Olive oil is a staple of most definitions of the Mediterranean diet; however, some Mediterranean cuisine includes lard and butter for cooking, and olive oil for dressing salads and vegetables
Mediterranean Diet
Reference/s: [166] [167] [168] [169]
The TLC Diet is a low-fat meal-plan variant that was recommended by the National Cholesterol Education Program, Adult Treatment Panel. It is the “diet” most often utilized in the conduct of lipid
clinical trials.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Total fat: 25–35% of daily calories ‒ Polyunsaturated fat: Up to 10% of total
daily calories‒ Monounsaturated fat: Up to 20% of total
daily calories• Carbohydrate: 50% to 60% of total calories• Soluble fiber: At least 5-10 grams a day,
preferably 10-25 grams a day• 2 grams per day of plant stanols or sterols
through foods or dietary supplements
Discouraged
• Limit saturated fat: < 7% of total calories• Limit cholesterol: < 200 mg a day• Avoid foods with trans fatty acids.
Therapeutic Lifestyle Change Diet (TLC)
Reference/s: [170] [171] [172]
The Atkins Diet is illustrative of a carbohydrate-restricted nutritional intervention which promotes utilization of fat for energy and generates ketosis, which may reduce appetite.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• The induction phase allows no more than 20 grams of carbohydrate per day from non-starchy vegetables and leafy greens; encourages adequate proteins from foods such as beef, pork, bacon, fish, chicken, eggs, and cheese, to reduce insulin levels and generate ketosis.
• The ongoing weight loss phase allows a wider variety of vegetables, seeds and nuts, and low-glycemic fruits (i.e., strawberries and blueberries).
• The pre-maintenance phase, after the goal weight is achieved, allows carbohydrate intake to be slowly increased as long as weight gain does not occur.
• In the maintenance phase, 60 to 90 grams of carbohydrates per day is allowed, which may allow legumes, whole grains, and fruits.
• All phases encourage a balance of saturated, monounsaturated, and polyunsaturated fatty acids.
Discouraged
Avoid:• Processed and refined foods• Foods with a high glycemic index• Foods rich in trans fatty acids
In all but the maintenance phase, limit:• Cereals, breads, and grains• Dairy products, except cheese• Starchy vegetables• Most fruits
Atkins Diet
Reference/s: [173] [174] [175]
The Ornish Diet is illustrative of a fat-restricted nutritional intervention.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Foods are best eaten in their natural form • Vegetables, fruits, whole grains, and legumes• One serving of a soy product each day• Limited amounts of green tea• Fish oil 3-4 grams each day• Small meals eaten frequently throughout the day
Discouraged
• Limit dietary fat: < 10% of total daily calories• Limit dietary cholesterol: < 10 mg per day• Limit sugar, sodium, and alcohol• Avoid animal products (red meat, poultry, and
fish) and caffeine (except green tea)• Avoid foods with trans fatty acids, including
vegetable shortening, stick margarines, and commercially prepared foods, such as frostings; cake, cookie, and biscuit mixes; crackers and microwave popcorn; and deep-fried foods
• Avoid refined carbohydrates and oils
Ornish Diet
Reference/s: [176] [177] [178]
The “Dietary Approaches to Stop Hypertension” (DASH) is a diet pattern promoted by the U.S. National Heart Lung and Blood Institute, primarily to treat high blood pressure.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Vegetables, fruits, and whole grains • Fat-free or low-fat dairy products• Fish, poultry, and lean meats• Nuts, seeds, and legumes• Fiber and the minerals calcium,
potassium, and magnesium
Discouraged
• Limit sodium: 1,500-2,300 mg per day • Limit total fat: ~27% of total daily calories• Limit saturated fat: <6% of total daily
calories • Limit cholesterol: <150 mg per day for a
2,100-calorie eating plan• Avoid red and processed meats • Avoid sugar-sweetened beverages• Avoid foods with added sugars
DASH Diet
Reference/s: [179] [180]
Paleolithic nutritional intervention is based upon a diet pattern presumed to exist during the Paleolithic period (lasting 3.4 million years, and ending 6000-2000 BC). It differs from some other diets in that it
excludes grains, dairy, and processed foods.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Fresh vegetables, fruits, and root vegetables
• Grass-fed lean red meats • Fish/seafood• Eggs• Nuts and seeds• Healthful oils (olive, walnut, flaxseed,
macadamia, avocado, and coconut)
Discouraged
Avoid:• Cereal grains• Legumes, including peanuts• Dairy products• Potatoes• Processed foods• Refined sugar, refined vegetable oils,
and salt
Paleolithic Diet
Reference/s: [181] [182] [183]
A vegetarian nutritional intervention includes a meal plan consisting of foods that come mostly from plants.
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Encouraged
• Vegetables• Fruits• Whole grains• Legumes• Seeds• Nuts• May include eggs and milk
Discouraged
• Fowl• Fish• Beef• Pork• Lamb
Vegetarian Diet
Reference/s: [184] [185]
Vegan (“Total Vegetarian”): Only plant-based foods (e.g., fruits, vegetables, legumes, grains, seeds, and nuts) with no animal proteins or animal by-products, such as eggs, milk, or honey
Lacto-vegetarian: Plant foods plus some or all dairy products (e.g., cheese)
Lacto-ovo Vegetarian (or Ovo-lactovegetarian): Plant foods, dairy products, and eggs
Semi or Partial Vegetarian: Plant foods and may include chicken or fish, dairy products, and eggs, but not red meat
Pescatarian: Plant foods and seafood
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Vegetarian Diet Variants
Reference/s: [184] [185]
The DIETFITS Randomized Clinical Trial• Published in JAMA, February 2018• Background
• To determine the effect of a healthy low-fat (HLF) diet vs a healthy low-carbohydrate (HLC) diet on weight change and if genotype pattern or insulin secretion are related to the dietary effects on weight loss.
• Methods• 609 adults (ages: 18-50) without DM and with a BMI between 28-40• Participants were randomized to 12 month HLF (n = 305) or HLC (n = 304) diet
• Intervention• 22 diet-specific small group classes were conducted over 12 months• Both groups emphasized
• Eating as many vegetables as possible• Choosing nutrient-dense whole foods & limiting processed foods• Preparing foods at home• Avoiding trans fats, added sugars, and refined carbohydrates
Gardner CD, Trepanowski JF, Del Gobbo LC, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion: The DIETFITS Randomized Clinical Trial. JAMA. 2018;319(7):667–679. doi:10.1001/jama.2018.0245
The DIETFITS Randomized Clinical Trial• Intervention
• Participants were instructed to reduce intake of total fat or digestible carbohydrates to 20 g/d during the first 8 weeks
• Then slowly added fats or carbohydrates back to their diets in increments of 5 to 15 g/d per week until they reached the lowest level of intake they believed could be maintained indefinitely.
• No explicit instructions for energy (kilocalories) restriction were given.• Encouraged to participate in 150 minutes per week of moderate aerobic physical activity
• Results• Mean macronutrient compositions
• HLF: 48% carbs, 29% fat, 21% protein• HLC: 30% carbs, 45% fat, 23% protein
• Weight change at 12 months• HLF: - 5.3kg• HLC: - 6.0kg
• Conclusion• No significant difference in weight change between HLF vs HLC diet.
The DIETFITS Randomized Clinical Trial• Intervention
• Participants were instructed to reduce intake of total fat or digestible carbohydrates to 20 g/d during the first 8 weeks
• Then slowly added fats or carbohydrates back to their diets in increments of 5 to 15 g/d per week until they reached the lowest level of intake they believed could be maintained indefinitely.
• No explicit instructions for energy (kilocalories) restriction were given.• Encouraged to participate in 150 minutes per week of moderate aerobic physical activity
• Results• Mean macronutrient compositions
• HLF: 48% carbs, 29% fat, 21% protein• HLC: 30% carbs, 45% fat, 23% protein
• Weight change at 12 months• HLF: - 5.3kg• HLC: - 6.0kg
• Conclusion• No significant difference in weight change between HLF vs HLC diet.
Physical Activity
At least 150 minutes (2.5 hours) per week of moderate physical activity or at least 75 minutes (1.25 hours) per week of vigorous intensity aerobic exercise = most health benefits, promote modest weight loss, and prevent weight gain
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Physical Activity
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Unable to Walk
• Seated exercise program • Arm exercises (i.e., arm cycling)• Swimming/aquatic exercises (e.g., shallow or
deep water exercises) • Gravity-mediated physical activity • Consider physical therapy evaluation
‒ Recommend rehabilitation & physical therapy guided activity program
‒ Set physical activity goals‒ Assess special equipment needs
Limited Mobility, Able to Walk
• Walking• Swimming/aquatic exercises (e.g.,
shallow or deep water exercises)• Gravity-mediated physical activity • Assess for special equipment needs
No Substantial Limitations to Mobility
• Exercise/physical activity prescription plan driven by patient and guided by clinician
• Assess for special equipment needs
Assess Mobility
Pathophysiology of Eating and Weight Regulation
Indications for Surgery
• BMI 40 or greater
• BMI 35 -40 with co-morbidities
• Patient must be an acceptable operative risk
• Patient must be motivated and demonstrates the ability to understand and participate in the program
• Patient must be dedicated to a major lifestyle change and long-term follow-up
• Consensus after bariatric team evaluation (Surgeon, Psychologist, Dietitian, etc.)
Normal GI Anatomy Roux-en-Y Gastric Bypass (RYGB) Anatomy
Sleeve Gastrectomy(SG) Anatomy
Pros Cons
Expected loss in percent
excess body weight* at two
years
Optimally suited for patients with: Other comments
Roux-en-Y Gastric Bypass
Greater improvement inmetabolic disease
Increased risk of malabsorptive
complications over sleeve
60-75% Higher BMI, GERD, Type 2 DM
Largest data set, more technically challenging
than LAGB, VSG
Vertical Sleeve Gastrectomy
Improves metabolic disease; maintains small intestinalanatomy; micronutrient deficiencies infrequent
No long term data 50-70% (*3- year data) Metabolic disease
Can be used as the first step of staged
approach; most common based on
2014 data
Laparoscopic Adjustable
Gastric BandingLeast invasive; removable
25-40%5 year removal rate
internationally
30-50% Lower BMI; nometabolic disease
Any metabolic benefits achieved are
dependent on weight loss
Biliopancreatic Diversion with
DuodenalSwitch
Greatest amount of weight loss and resolution of
metabolic disease
Increased risk macro-and micronutrient
deficiencies over bypass70-80% Higher BMI, Type 2
DMMost technically
challenging
*Excess body weight (EBW) = (total body weight) - (lean body weight)
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association. Reference/s: [332] [333]
Macro- and Micro-nutrient Digestion and Absorption
• Macronutrient digestion begins in mouth and stomach and continues in duodenum
• Absorption of macronutrients occurs largely in duodenum and jejunum but continues throughout small intestine
• B12 absorption requires intrinsic factor (found in gastric acid)
• Ferric iron is converted to absorbable ferrous iron in gastric acid
• Vitamin D & folate absorbed in jejunum• Calcium absorption is dependent on pH and
vitamin D status
Reference: Kursheed N. Jeejeebhoy, Short bowel syndrome: a nutritional and medical approach., KhuCMAJ May 2002, 166 (10) 1297-1302;
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
Large IntestineStomach Duodenum Jejunum Ileum
• Water• Sodium chloride• Potassium• Intestinally
derived vitamin K
• Water• Alcohol
• Fatty acids• Amino acids• Minerals (e.g.,
calcium during calcium deficiency, iron)
• Some vitamins
Due to length and location, the jejunum absorbs the greatest amount of:• Simple sugars• Fatty acids• Proteins• Minerals• Vitamins
• Bile salts• Bile acids• Vitamin B12• Some vitamins• Some minerals
Nutrient Absorption
Reference/s: [37] [320]
• Restriction
Adjustable Gastric Band
Sleeve Gastrectomy
• Restrictive procedure – limits amount of food patient is able to eat
• 80% of stomach is removed• Pyloric sphincter and intestines remain intact
so food pathway is not altered• Effect on gut hormones
• GLP-1 increased (satiety)• PYY increased (satiety & GI mobility)• Ghrelin decreased (hunger)
• 2 years post-surgery – 25% weight loss of initial weight
Reference: Pournaras DJ, le Roux CW. Obesity, gut hormones, and bariatric surgery. World J Surg. 2009;33(10):1983-1988
Roux-en-Y Gastric Bypass• Restrictive & malabsorptive procedure
• Small gastric pouch (30 mL) is attached to jejunum
• Stomach remnant & duodenum are reattached to create common channel
• Effect on gut hormones• GLP-1 increased (satiety)• PYY increased (satiety & GI mobility)• Ghrelin inconclusive (hunger)
• 2 years post-surgery – 35% initial weight loss
• 10 years post-surgery – 25% initial weight loss
Duodenal Switch
• Minimal weight regain
• High resolution of diabetes
Bariatric Surgery: Common Micronutrient Deficiencies Vitamins Minerals
A B1 B9 B12 D* E K Ca Fe Zn/Cu
RNY X X X X X X
Sleeve X X X X X
LAGB X X
BPD X X X X X X X X X X
Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.
*Vitamin D deficiency is seen in a significant number of patients with obesity at baseline. However, due to malabsorption, the risk is further increased post-op.
For a complete explanation of micronutrient deficiencies, refer to “Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient” at www.asmbs.org.
Reference/s: [320] [366]
Micronutrient Pre-WLS Screening Recommendation Deficiency Rates
Thiamin Recommended Patients with obesity - <29%
B-12 Recommended Patients with obesity – 2-18%PPIs – 6-30%
Folate Recommended Patients with obesity – 54%
Iron Recommended Patients with obesity – 45%
Calcium Recommended Elevated values of CTX reported in 66.7% of patients < 50 yo
Vitamin D3 Recommended Patients with obesity – 90%
Vitamin A Recommended Patients with obesity – 14%
Vitamin E Recommended Patients with obesity – 2.2%
Vitamin K Recommended No data on pre-WLS patients
Zinc Recommended Pre-WLS – 24-28%
Copper Recommended Pre-WLS - <70%
ASMBS 2016 Nutrient Screening Recommendations
ASMBS 2016 Supplement Guidelines for WLSMicronutrients Sleeve Gastrectomy Roux-en-Y Gastric Bypass
MVI 100% RDA (1-3 months) 200% RDA
B-1 (thiamin) 50 mg/day (from B-complex or MVI)
B-12 350-500 ug/d (oral/sublingual/nasal) or 1,000 ug/month intramuscularly
Folate 400-800 ug (from MVI)800-1000 ug for pre-menopausal women
Iron 45-60 mg elemental iron
Calcium 1,200 mg for men & pre-menopausal women1,500 mg for post-menopausal women
Vitamin D3 3000 IU/d
Vitamin A 5000-10,000 IU/d
Vitamin E 15 mg/d
Vitamin K 90-120 ug/d
Zinc 100% RDA (8-11 mg/d) 200% RDA (16-22 mg/d)
Copper 100% RDA (1 mg/d) 200% RDA (2 mg/d)
Results of Bariatric Surgery*
• Improvement or resolution of obesity-related medical problems
• Increased longevity• Improved quality of life
• psychological• health• social• personal• work
• Weight loss
*Results achieved in most, but not all cases. Degree of improvements vary by individual
Resolution of Obesity-related Conditions
Sleep Apnea 75%
Stress Incontinence 87%
GERD 98%
Hypercholesterolemia 97%
Type 2 Diabetes 95%
Hypertension 92%
Cardiac Function Improvement 95%
Osteoarthritis 82%
Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obese Surg 2000.
NUTRITION MEDICAL WL
SURGICALWL
Conclusion• Best diet is one that can be maintained for life• Diet should be composed of high-quality,
nutritious whole foods• Mostly fruits and vegetables• Avoid flours, sugars, trans fats, and processed foods
• Strive to be physically active• 2.5 hours of moderate aerobic activity per week
• Stress management• Adequate sleep (7-9 hrs/night)
Thank you!